Muscular Architecture and Manometric Image of Gastroesophageal Barrier in the Rat

The two components of the gastroesophagealbarrier, the sphincter and the crural sling, closelyoverlap in humans, whereas they are widely separated inthe rat. This investigation correlates the anatomical components of the barrier and their manometriccounterparts in this animal. Sphincteric and cruralsling pressures were measured in four quadrants in 23rats. Muscle thickness was measured at nine levels of the gastroesophageal junction in the samequadrants in 12 rats and the muscular architecture ofthe region was studied in 10 fresh specimens. Themanometric sphincteric component is stronger on theright side where the thickest muscle fibers anchor tothe anterior and posterior borders of a mucosal ridgethat almost surround the cardia. Conversely, the slingpressure is highest towards the left where the muscular bundles straddle the esophagus. Inconclusion, there is a close correspondence between themanometric image and the muscular architecture of thecomponents of the gastroesophageal barrier in the rat. The anatomical arrangement of U-shapedmuscular bundles oriented in opposite directions createsa particularly powerful antireflux mechanism.     

Anal Ultra Slow Waves (A Smooth Muscle Phenomenon Associated with Dyschezia)

Anal ultra slow waves (USWs) have been describedin a variety of anorectal disorders, all of which may beassociated with constipation. We investigated whetherthey represent a marker for dyschezia and whether their occurrence can be modified.Manometric and endosonographic studies were performed in25 patients with dyschezia, in 25 age- and sex-matchedcontrols, and in an equal number of patients with hemorrhoids. Patients exhibiting ultra slowwaves were repeatedly studied with and without localadministration of isosorbide dinitrate. In addition, wedetermined whether stimulatory maneuvers modify the occurrence of USWs. Anal USWs were persistentlyfound in 56% of patients with dyschezia, in 8% ofpatients with hemorrhoids, and in none of the healthycontrols. They were stimulated by anal squeeze and completely abolished by local administration ofisosorbide dinitrate. Ultra slow waves always occurredin conjunction with an increase in anal resting pressureand were tightly associated with a fluctuation in slow wave amplitude. Anal sphinctermorphology was similar in patients with dyschezia and incontrols. We conclude that anal USWs occur mostfrequently in patients with dyschezia and indicatesmooth muscle dysfunction. Treatment directed atabolishing this motor phenomenon may represent a novelapproach to the management of patients withdyschezia.     

Achalasia (The Usefulness of Manometry for Evaluation of Treatment)

Although manometry is used with increasingfrequency to evaluate the effectiveness of differenttreatments for achalasia, the criteria for a successfulmanometric response have not been well defined.Manometric responses were collected before and after 43treatments in 35 patients with achalasia in order todetermine manometric changes after different clinicaloutcomes: 15 unsuccessful outcomes and 28 successful outcomes were reported. In the latter, restingpressure of the lower esophageal sphincter decreased to12.8 mm Hg, whereas in unsuccessful outcomes this wassignificantly higher (28.2 mm Hg). A decrease of lower esophageal sphincter pressure below 17mm Hg or more than 40% of the pretreatment level wasassociated with successful outcomes. Our data suggestthat manometry is a good indicator of therapeutic effectiveness and we propose that it be usedsystematically for objective evaluation of achalasiatreatment.     

Comparison of Ultrasound-Secretin Test and Sphincter of Oddi Manometry in Patients with Recurrent Acute Pancreatitis

Manometry is considered the gold standard forevaluating sphincter of Oddi dysfunction. It hasrecently been demonstrated that the ultrasound (US)secretin test proposed a few years ago as a noninvasive test for the study of sphincter of Oddidysfunction yields a substantial percentage ofpathological findings in patients with acute recurrentpancreatitis. The aim of this study was to compare theresults of the US secretin test with sphincter of Oddimanometry findings in a consecutive series of patientswith recurrent acute pancreatitis. Forty-seven patientsadmitted to our gastrointestinal unit suffering from recurrent acute pancreatitis underwentultrasonographic measurement of the main pancreatic ductat baseline and for 60 min after maximal stimulationwith secretin at 1 IU/kg. According to the US secretin test findings in 35 healthy control subjects,the test results were considered to indicate pathologywhen the duct was still dilated after 20 min. Withinthree to seven days the same patients underwent perendoscopic manometry. Thirty-six patients(17 men, 19 women; mean age 41 ± 15 years) had asuccessful US secretin test and sphincter of Oddimanometry. Eleven patients (30.6%) presented normalmanometric findings. Two of these had an abnormal USsecretin test. Twenty-five patients had abnormalmanometry findings, revealing stenosis in 19 (52.7%) (17with abnormal US secretin test) and dyskinesia in six (five with an abnormal US secretin test).Compared to manometry findings, the US secretin testsensitivity and specificity for sphincter of Oddidysfunction were 88% and 82%, respectively. Inconclusion, most patients with recurrent acute pancreatitishave sphincter of Oddi dysfunction documented by both atthe US secretin test and sphincter of Oddi manometry;results of the US secretin test are reliable compared to sphincter of Oddi manometry, andtherefore the US secretin test may offer a validalternative to the more expensive and invasivemanometric procedure for assessing sphincter of Oddidysfunction in patients with recurrent acutepancreatitis.     

Effects of Biofeedback Therapy on Anorectal Function in Obstructive Defecation

Biofeedback therapy improves symptoms inpatients with constipation and obstructive defecation.Whether it also improves anorectal function is unclear.Our purpose was to investigate prospectively the effects of biofeedback therapy on subjective andobjective parameters of anorectal function in 25consecutive patients with obstructive defecation.Biofeedback therapy consisted of pelvic floor relaxationexercises (phase I) and neuromuscular conditioning ofrectal sensation and rectoanal coordination, with asolid state manometry system and simulated defecationmaneuvers (phase II). The number of sessions wascustomized for each patient. Clinical improvement wasassessed from the changes in anorectal manometry,balloon (50 cc) expulsion test, and the symptom andstool diaries. The number of therapy sessions varied[mean (range) = 6 (2-10)]. After therapy, whenstraining as if to defecate, the percentage analrelaxation, intrarectal pressure, and defecation indexincreased (P < 0.001). The balloon expulsion time,laxative consumption, and straining effort decreased (P< 0.001). Before therapy, 16/25 (64%) patients hadimpaired rectal sensation, and after therapy thisimproved (P < 0.001). After therapy, 15/25 (60%) patients reported 75% satisfaction with bowelhabit and 8/25 (32%) reported 50% satisfaction (P< 0.001); 15/16 (94%) patients discontinued digitaldisimpaction. Biofeedback therapy not only improves subjective but also objective parameters ofanorectal function in at least 76% of patients byrectifying the underlying pathophysiologicdisturbance(s). Sensory conditioning and customizing thenumber of sessions may offer additionalbenefits.     

Esophageal Swallowing Phase Assessed by Audiosignal Recording (Relationship with Manometry in Gastroesophageal Reflux Disease Patients)

The acoustic technique has been used forpharyngeal exploration but to date no such technique hasbeen devised to assess esophageal motility. The aim ofthis study was to demonstrate that displacement through the esophagus can be quantified using thismethod in healthy subjects and in patients withgastroesophageal reflux. Concurrent manometric andacoustic recordings were also performed in the patients.Fifteen controls (38.5 ± 13 years old) and 10patients (34.9 ± 6 years old) were included. Allwere recorded during wet and dry swallow sequences withmicrophones placed below the cricoid cartilage and onthe xiphoid appendix. Standard manometry wasperformed for lower esophageal sphincter (LES)exploration. For the acoustic technique, the frequencyof xiphoid signals (FX), esophageal transit time (ETT),duration of xiphoid sound (SD), and for the manometricstudy, the duration of LES relaxation (RD) were recordedand mean values were calculated (FXm), (ETTm), (SDm),(RDm). FXm for wet (94 vs 81.6%) and dry swallows (86 vs 66.6%) decreased in patients. ETTm wassignificantly higher (P < 0.01) for wet than for dryswallows (5.6 ± 0.9 vs 5.2 ± 1.2 sec) forcontrols but not for patients. ETTm was significantly higher for patients for wet (7.2 ± 2.1sec) and for dry swallows (6.5 ± 2.3 sec) thanfor controls and SDm was lower. Xiphoid sound appearedin the second half of LES relaxation. Our noninvasiveacoustic technique is simple and reproducible. It iswell correlated with manometry, and it allowscharacterization of the displacement of the bolusthrough the esophagus and the LES. The technique couldbe used alone to determine appropriate pharmacologicaland surgical treatments for esophageal motilitydisorders.     

Esophageal Motor Function in Primary Sjögren's Syndrome Correlation with Dysphagia and Xerostomia

The incidence of dysphagia in patients withprimary Sjögren's syndrome (pSS) has beenunderestimated and all too often ascribed to xerostomia,without considering the possible presence of esophagealmotor abnormalities affecting other nonsclerodermaconnective tissue diseases. Esophageal and salivaryfunctions were prospectively evaluated in 27 females whomet the four criteria proposed by Fox for the diagnosis of pSS, using esophageal manometry after wetswallows and Saxon's test, respectively. Dysphagia wasgraded using a standard symptoms questionnaire andresults were compared with those obtained in a group of 21 healthy controls. Seven patients with pSS(26%) had no swallowing discomfort, 2 (7.4%) had milddysphagia, 7 (26%) had moderate dysphagia, and 11(40.6%) had severe dysphagia. Saxon's test revealed an overall decrease in the salivary flow ratecompared to controls, with no difference betweenpatients with or without dysphagia. Esophageal manometrydemonstrated the absence of any lower or upperesophageal sphincter function abnormalities in allpatients. In the patients with pSS as a whole,manometric study of the esophageal body showed a motorpattern comparable with that of controls, with nodifference between patients with and without dysphagia.Defective peristalsis, ie, the presence of simultaneouscontractions in more than 30% of wet swallows wasdetected, however, in the distal tract of the esophagus of six patients (22.2%) and in the proximaltract of three (11.1%). All these patients had severedysphagia and the modified Saxon's test revealed asalivary secretion comparable with that of patients with a normal peristalsis. Dysphagia is a verycommon complaint in patients with pSS and does not seemto correlate with xerostomia, which is a constant andtypical finding of the disease. About one third of patients with pSS have an abnormal esophagealperistalsis that is responsible for severe dysphagia,whereas decreased salivary outflow exacerbates theswallowing discomfort. This has to be taken into account and justifies the routine use of esophagealmanometry in patients with pSS. The cause of dysphagiain pSS patients without peristaltic disorders of theesophagus has to be investigated.     

Risk Factors for Diagnostic Delay in Achalasia

This study investigates whether the frequentlydelayed diagnosis of achalasia is attributable toatypical symptoms, misleading diagnostic features, orthe number of physicians consulted. Eighty-sevenconsecutive patients with newly diagnosed achalasia wereprospectively investigated with the use of structuredinterviews as well as manometric, endoscopic, andradiographic studies. The mean duration of symptoms was 4.7 ± 6.4 years. Quality and intensityof symptoms had no effect on early diagnosis. Amongdifferent radiographic and manometric features, only thewidth of the gastric cardia showed a significantcorrelation with a delay in diagnosis (P < 0.01).However, the most significant association was foundbetween the duration of symptoms prior to consideringthe diagnosis of achalasia and the number ofunsuccessful physician consultations (P = 0.001). We conclude that thefrequent delay in the diagnosis of achalasia is not dueto an atypical clinical presentation of this disease butrather to misinterpretation of typical findings by the physician consulted.     

Effect of Laparoscopic Gastric Banding on Esophageal Motility

Background: Alterations in esophageal motility may occur after placement of an adjustable gastric band as treatment for morbid obesity, near the gastro-esophageal junction. It causes an outlet obstruction, especially during follow-up after the band is filled. Methods: 29 morbidly obese patients underwent conventional manometry preoperatively, 6 weeks postoperatively before and after filling the band and at 6 months postoperatively. A questionnaire was used to assess upper gastrointestinal symptoms during follow-up. Results: After band placement, there was a significant increase in lower esophageal sphincter (LES) end-expiratory pressure at 6 weeks with an empty band: 1.3 (0.9-1.9) kPa (median (interquartile range) (P=0.003), 6 weeks with a filled band: 2.1 (1.5-2.8) kPa (P=0.0001), and at 6 months: 1.5 (1.3-1.9) kPa (P=0.001), compared to the preoperative pressure: 0.8 (0.6-1.3) kPa. Also after band placement, the high pressure zone length increased (preop 5.0 (4.3-6.0) cm vs 6 weeks 6.0 (5.0-6.5) cm (P=0.003). The propagation of peristaltic contractions was not significantly altered after band placement. Heartburn decreased 6 weeks postoperatively (P=0.04) but increased at 6 months. Heartburn at 6 months was correlated with pouch formation (0.667; P<0.01). Conclusion: Adjustable gastric band placement causes an increase in LES pressure and length of the high pressure zone. It decreases reflux symptoms in the short-term, but this effect appears not to be related to an effect on LES pressure or length. Pouch formation increases reflux symptoms without having any relationship to LES pressure and length. Band placement in the short-term does not disturb propagation of esophageal contractions.